Healthcare Provider Details

I. General information

NPI: 1982150934
Provider Name (Legal Business Name): UF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2016
Last Update Date: 08/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 CENTER DR # D8-18
GAINESVILLE FL
32610-0406
US

IV. Provider business mailing address

1333 NW 117TH TER
GAINESVILLE FL
32606-0422
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-7755
  • Fax:
Mailing address:
  • Phone: 352-226-4651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number
License Number State

VIII. Authorized Official

Name: LEE TAMMY
Title or Position: ADMINISTRATIVE SPECIALIST
Credential:
Phone: 352-273-5688